Awake subxyphoid minimally invasive direct coronary artery bypass grafting yielded minimum invasive cardiac surgery for high risk patients

Abstract

Off-pump coronary artery bypass graft (CABG) surgery has become a widely used modality and has received recognized as a minimally invasive surgery with few complications. However, for patients with severely impaired pulmonary function, further considerations have to be given to reduce the complications associated with general anesthesia. We have accumulated experience in awake off-pump surgery combined with high thoracic epidural anesthesia. In this report we describe the use of alternative subxiphoid approach in patients with severe pulmonary dysfunction. A catheter for high thoracic epidural anesthesia was inserted one day before surgery. After obtaining an adequate level of anesthesia, a small subxiphoid incision was made and the pericardium was opened to expose the left anterior descending branch. The conduit for bypass, gastroepiploic artery was accessed through a minilaparotomy, and separated under the same surgical field and anatomozed under beating heart. This procedure was performed in three patients. Patency was confirmed by postoperative angiography in all three cases. All patients were discharged after an uneventful postoperative course. Awake subxiphoid approach has the advantages that both thoracotomy and sternotomy can be avoided thus permitting surgery with extremely low invasiveness. This method is recommended for patients with severe pulmonary dysfunction.

Off-Pump Coronary Artery Bypass Grafting Revisited: Experience and Evidence from Japan

“…Watanabe, et al 14) reported awake subxiphoid CABG in 3 patients with severe pulmonary dysfunction. A catheter for high thoracic epidural anesthesia was inserted 1 day before surgery, and under the appropriate amount of epidural anesthesia, the right gastroepiploic artery was harvested through a small subxiphoid incision, and the artery was anastomosed to the left anterior descending artery (LAD).…”

Harvesting bilateral internal thoracic arteries using a novel subxiphoid approach versus the conventional lateral thoracic approach—results of an experimental study

“…Although cardiac surgery has lagged far behind other specialties in the development of robot-assisted minimally invasive surgery, significant advances have been made, and encouraging reports have emerged. [10][11][12][13] The superiority of ITA as a conduit has been well established for long-term patency and event-free survival. Robotic assistance has allowed BITA grafting to be performed through a minimally invasive access method.…”

“…Finally, new surgical approaches usually contain a steep learning curve, 10 which could also be the case with the robot-assisted subxiphoid approach.…”

Superficial temporal artery–middle cerebral artery bypass using local anesthesia and a sedative without endotracheal general anesthesia

“…The awake coronary artery bypass graft is now a well-established technique, and it is known to decrease the adverse side effects typically associated with general anesthesia and mechanical ventilation. 11,14,16,17,23 Awake craniotomies have traditionally been performed for epilepsy surgery and neurooncological operations for tumors involving the eloquent cortex. 12,20 With the development of improved anesthetic techniques and more sophisticated neuronavigation equipment, awake craniotomy has become a fast, safe, and effective procedure with good patient tolerance.…”